Sydney Martin - Professional Lecture - Activities of Daily Living, Fine Motor Skills and Sensory...

Activities of daily living, fine motor skills and sensory strategies for children with Down Syndrome

Sydney Martin, MS OTR Children’s Hospital Colorado

Outline

•  Medical Characteristics •  Fine motor skills •  Activities of daily living for Children & Adults •  Visual Supports for Daily Living •  Sensory Integration •  Modulation, Behavior & Self-regulation •  Sensory Diet •  Questions and Answers

Characteristics •  Hypotonia

§  Joint Laxity

•  Hand Characteristics §  Smaller hands §  Single Simean Crease §  Wrist Bones §  Clinodactyly (Curved 5th finger)

•  Medical §  Cardiac §  Susceptibility to infections §  Hearing loss

•  Cognitive §  Developmental Delays §  Attention difficulties 3

Occupational Therapy Domain Areas of Practice

•  Sensory and self regulation •  Social skills and emotional regulation •  Fine motor, visual motor skills •  Attending, listening and processing •  Self-help, including eating, dressing, grooming, bathing,

toileting and chores •  Cognitive functions

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Fine motor skills •  Postural Control •  Trunk and shoulder stability •  Reach, grasp and release •  Play •  Dexterity skills for school, daily living skills •  Assistive technology •  Pre-Writing & Writing •  Vocational skills

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Developmental Considerations Postural skills

Trunk Control Shoulder stability (fine motor/dexterity)

Play

Language Self-Care

Social interaction

Engagement in purposeful activities

Postural Skills •  Trunk Control •  Stability •  Stability with gross motor tasks •  Rotation •  Facilitation of reach and grasp •  Shoulder Stability

§  Strengthening activities •  Shoulder •  Placing weight on arms and hands in play •  Promoting arch development •  Fine motor skills •  Motivation during play •  Fun Activities

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Reach, Grasp & Release •  Reach

§  Requires shoulder stability §  Motivation to reach & play

•  Grasp §  Pinch §  Thumb control-opposition §  Wrist movement §  Finger control & coordination §  Types of grasp

•  Palmar •  Pronated •  Tripod •  Pincer (Pinch)

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Dexterity Skills •  Finger Coordination

§  Moving fingers individually §  Poking, pointing §  Holding pencil §  Scissors

•  Wrist §  Turning hand over §  Sensory play §  Self help skills §  Dressing & Fasteners §  Opening lids

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Bilateral Coordination •  Scissor Skills •  Pre-Scissor skills

§  Tearing paper §  Squeeze or loop scissors §  snipping

•  Scissor Skills §  Cutting Straight line §  Move to curved lines §  Shapes §  Hand Strength- spray bottle, squeeze activities

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Printing & Pencil Grasp •  Pre-Printing

§  Markers & Crayons §  Sensory play-sand, clay,

shave cream §  Use Stickers to target and

connect the lines §  Printing §  Vertical surface/wall or

Chalkboard §  Vertical & horizontal

Orientation §  Left to Right §  Sensory play with writing §  Shoulder stability §  Start & Stop

§  www.HWTears.com

§  www.TVTeacher.com

Assistive Technology •  Touch screen programs •  Trackballs- offer better control •  Joy Sticks •  Track pads •  Key guards •  Alternative keyboards

Developmental Considerations Praxis

Initiation, Planning, & Sequencing

Imitation (motor and oral-motor)

Play

Language Self-Care

Social interaction

Engagement in purposeful activities

Teaching Strategies for Activities of Daily Living

•  Intensive Toilet Training •  Chaining •  Picture Activity Schedules •  Video Modeling •  Practice and repetition •  Daily Living Social Stories

Independence in Self Care and Adaptive Skills

•  Wiping at the toilet •  Brushing Teeth •  Brushing Hair •  Showering •  Dressing

•  Making a snack •  Doing the laundry •  Washing dishes •  Setting the table •  Getting bag ready

for school

Chaining •  Chaining is a very useful basic teaching procedure that

you can use for these kinds of skills •  Chain

§  Multi-step actions where all steps have to occur in the correct sequence to finish the task correctly

Chaining Interventions

Backward Chaining

Forward Chaining

TASK ANALYSIS

Chaining

Importance of a chain

•  Each completed step serves as a cue for the next relevant action §  If the chain is interrupted you may lose some steps

in the sequence

•  Examples of Chains §  Tying shoes, making a sandwich, starting a car

•  Before a chain is taught you have to identify every step using a TASK ANALYSIS

Teaching a step in the chain

§ Present initial instruction (e.g., “Put on your shirt.”) • Present the steps instruction (e.g.,“Place

shirt over your head.”) • Use prompts if needed • Use reinforcement for correct responses as

needed • Fade prompts • When behavior occurs without prompts,

move to the next step

Linking Steps Together: Backward Chaining

•  All steps are completed for the client, except for the last, then second to last, etc. §  1-2-3-4-5 (therapist) 6 (client) … mastery §  Example: the shirt and one arm is placed into

the shirt– Child has to put other arm in. §  Reduce prompts as you go for mastery

•  Use when there is a natural reinforcer at the end of the chain– I’m Dressed!

•  Use when task termination is a reinforcer

Forward Chaining

•  Teach the steps in a forward manner, 1 at a time §  1 (reinforcer)… mastery §  1-2 (reinforcer)… mastery §  1-2-3 (reinforcer)… mastery, etc.

•  Use when the client can perform each of the steps

•  Use when the initial steps are easiest

Nail Trimming •  Always after or during bath time when the nails are soft •  Don’t use the word “cut” use the word “trim” •  Provide heavy work activity before •  Video the family trimming their nails & have child watch •  Introduce nail trimmers to cut onto paper first in play •  Slowly introduce nail trimming to your child when they

are calm •  Break the activity into steps •  Take breaks and offer a pleasurable activity during nail

trimming.

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Haircuts •  Take Child to watch the hairdresser •  Complete heavy work activities before •  Use a towel and clip instead of cape •  Take along an extra shirt to change into •  Visual distraction- computer or IPAD •  Sit on parents lap •  Reward with positive reinforcement •  Consider having a hair dresser come to your home if

necessary

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Schedules

Visual Schedule

Picture

Written

Tech Based

Why use activity & Visual schedules? •  To increase behavior that has been learned but is not

occurring independently §  Pre-teach a skill §  Improve Independence

•  To reduce problem behavior during transitions

•  To teach new sequences of behavior and learn new skills

Prerequisite Skills

•  Ability to discriminate pictures from backgrounds

•  Identify matching with 3D objects

•  Identity matching with picture to object

•  Tolerance of manual guidance

•  Ability to manipulate materials

Visual organizers •  Visual Schedules

Picture Exchange Communication System-PECS

Routine-based Strategies Work systems

The individual work system answers four questions 1. What work? 2. How much work? 3. How do I know when I am

finished? 4. What happens next?

http://www.teacch.com/

First this – Then that…

Visual Schedule First - then

Ready/Not Ready •  Teach child to indicate if they are “ready” or “not

ready” •  Associate “not ready” with a means to get “ready”

§  then move them into getting ready §  finally, engage in task at hand because they are “ready”!

Sensory Integration

Pyramid of Learning

Sensory Integration •  Sensory integration is a neurological process •  Theory that describes the relationship and association

between behavior and neurological processes •  “The neurological process that organizes sensation from

one’s own body and from the environment and makes it possible to use the body effectively within the environment.” (Ayres, 1979)

•  The ability to receive, interpret and organize sensory information (i.e. Self Regulation)

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A Model for Understanding Sensory Modulation

Sensory Integration-Based on Ayres

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Frick, Wilbarger

Ayres’ Model of Praxis

Ideation

Planning

Execution Ayres Model of Praxis

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Dunn’s Model of Sensory Processing

Sensation seeking

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POOR REGISTRATION

Sensory avoiding

Lane, C. 2011

Sensory Modulation •  Taking in sensory information •  Processing sensory information •  Functioning within an Optimal Range

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Disruption with Sensory Modulation

•  Observe behavioral difficulties •  Sensory avoidance •  Irritability •  Sensation seeking •  Poor coping and self-regulation

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S.T.E.P.S.I. •  Model of Sensory Integration designed by Stackhouse &

Wilbarger

•  S ensation •  T ask •  E nvironment •  P redictability •  S elf Monitoring •  I nteraction

Copyrighted to Stackhouse and Wilbarger

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Goal of OT with SI Treatment •  Purposeful activity and Goal oriented responses •  Facilitation of the adaptive response •  Based on integration of sensory and motor input •  Self-regulation •  Motor planning •  Improving the child’s organization of neural and sensory

information to adapt effectively to their environment

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Classical SI – Bottom UP •  The use of sensation through the adaptive response produces sensory integration, the basis of praxis & motor planning

•  Qualities of sensation include focused work on foundation of disorder §  Vestibular §  Tactile §  Proprioception

Adaptive Response

How We Treat Sensory Issues •  Careful analysis of the problem •  Sensory Diet & Sensory Based Activities •  Classroom, Home and Community based Program instructions & suggestions

Sensory Systems

•  Vestibular (movement) •  Tactile •  Proprioception (heavy work) •  Auditory •  Olfactory •  Visual

Sensory Diet Components •  Proprioceptive & Tactile discrimination activities •  Movement (Vestibular) input •  Mouth activities: Organizing & Self-Regulation •  Auditory input: Music, listening programs •  Effective strategies for transitioning •  Reducing behavioral outbursts •  Help with shifting •  Task and environment modification

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Self-Regulation is the Key •  “Self-regulation is the ability to attain, change, or

maintain an appropriate level of alertness for a task or situation.” (Williams & Shellenberger 1996).

•  Self Regulation helps us to adapt to our environment •  Coping skills and Calming skills

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Movement

Information to muscles and joints

Alertness Strategies

The Sensory Diet Concept •  Originated by Patricia Wilbarger, M.A., OTR

Sensory Diet Components

•  Routines for transitions •  Family lifestyle and preferences assessed and

modified •  Can be used during new learning •  Task/activity modification •  Environmental modifications

The Key is Building a Daily Schedule Event/Time

Sensory Diet Activity

Transition Other Support

Wake -Up

AM Lunch Early PM

Dinner Bed-time

Sensory Based Strategies Movement: Modalities

§  What sensory receptors are stimulated?

§  What areas of the brain are activated?

§  How does it effect arousal & alertness?

§  How does it support function?

•  Intensity •  Frequency •  Duration •  Rhythmicity

The Relationship of Arousal to Attention, Learning and

Performance GOOD

ADAPTIVE RESPONSE --------------------------------------------------------------------------- (Attention, Learning, Performance) POOR __________________________________________________________

LOW ⇑ OPTIMAL RANGE ⇑ HIGH OF AROUSAL

After Hebb, 1949

Arousal-Relaxation Cycle Builds Self-Regulation

Child

experiences a “need”

Child feels upset

Adult satisfies need

Child Feels Content/organized

behavior

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Sensory Strategies

•  Sensory Play •  Tactile •  Heavy Work •  Movement (Vestibular) •  Auditory (music) •  Oral Proprioceptive •  Visual

•  Cozy corner •  Headphones •  Therapy ball •  Movement Activities

Ziggurat Model

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Aspy, Grossman, 2008

Education and Advocacy •  Education

§  School & community personnel §  Explaining learning strategies §  Explaining behavioral differences

•  Advocacy §  Educating about Down Syndrome conditions §  Teaching strategies for success §  Promoting success across all environments

Resources •  “Fine Motor Skills for Children with Down Syndrome” by

Maryanne Bruni, BScOT •  The Sensory-Sensitive Child: by Smith & Gouze •  “How Does Your Engine Run” www.thealertprogram.com •  www.texasautism.com Ziggurat Model •  www.southpawenterprises.com •  www.therapro.com •  www.Therapyfunzone.com •  www.sensorycomfort.com •  www.softclothing.net

Thank you for your Attention! Contact Information: Syd Martin MS, OTR Children’s Colorado Hospital Email: Sydney.Martin@Childrenscolorado.org